(G.P.V.

) --- Y-1531-
20,000-1-2006

ESIC DECLARATION FORM

Form 1
To be filled in only if the employee after reading instruction overlief. Two Postcard size photographs are to be attached with this form. This form is free of cost.

(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

1. Insurance No. Employer's Code No.
2. Name
Date of Appointment
(In Block capital)

3. Father's / Name & Address of the employer

Husband's Name
DD/MM/YYYY Maritail Status Sex
Date of Birth

12.In case of any pervious employment please fill up

Present Address Permanent Address
the details as under :-
a) Pervious ins. No.
b) Emplrs. Code No.
c) Name & Address of the employer with Telephone
Pin Code Pin Code No & E-mail Address

Mobile No & Mobile No &

E-mail Address E-mail Address

Bank A/c. IFSC Code

NIL
Bank Name Bank Add

Branch Office Dispensary

Details of the Nominee u/s 71 of ESI Act 1948/ Rule 56(2) of ESI (Central Rules, 1950 for paymemt of cash benefit in the event of death.

Name Relationship Address

I Hereby declare that the particulars given by me are correct to the best of my knowledge and belief, I undertake to intimate the corporation any changes in the
membership of my family within 15 days of such change.

Counter Signature by the employer

 ______________________________________
k.lavanyarahuk

Signature/ T.I of
Signature with seal
IP

FAMILY PARTICULARS OF INSURED PERSON

Date of Birth/ Whether residing with If 'NO' state place of

Relationship with him/her? Residence
Sr No. Name age as on date
the Employee
of form filling Yes No Town State
1
2
3
4
5
6
7
8
--------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------

Name

Date of
1. Insurance No. Appointment
(Space for Photograph)

Branch Office Dispensary

Employeer's code No.& Address

Validity

k.lavanya
 -------------------------------
Date
----
Signature/ T.I of IP Signature of B.M. with seal
 INSTRUCTIONS

1 Submition of Form-I is governed by regulation 11 & 12 of ESI (General ) Regulation 1950.

2 "Family means all of any of the following relatives of an Insured Person Namely:-

(i)a Spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who is
wholly dependence on the earning of the I.P. and who is (a) receiving education, till he or she
attains the age of 21 years (b) an unmarried daughter; (iv)

3 Identity card is Non- transferable.

4 Loss of Identity card be reported to the employer / Branch Manager immediately.

5 Submission of false infoemation attacts pencil action under section of 84 of ESI Act, 1984.

6 This form duly filled in must reach the concerned Branch Office eithin 10 days of appointment of an Employee

As an Insured person you and your dependent family members are entitled to full medical care.
7 The other benefit in cash include (1) Sickness benefit (2) Temporary disablement benefit (3)
Permanent disablement benefit (4) Dependence Benefit and (5) Materni

8 For more details visit website of ESIC at www.esic.org. in or contact Regional office or Branch Office.

For Branch Office Use Only

1. Date of allotment of Ins. No

1. Date of allotment of Ins. No

1. Date of allotment of Ins. No

1. Date of allotment of Ins. No

Whether residing with If 'NO' state place of

Relationship
him/her? Residence
Sr No. Name Date of Birth/ age as on date of form filling with the
Employee
Yes No Town State

7
8
 THE PAYMENT OF GRATUITY RULE, 1972

FORM - F
(See sub-rule (1) of rule 6)

WNS

below, hereby

I hereby certify that the person(s) mentioned is/are member(s) of my family within the meaning of
clause(h) of section 2 of the Payment of Gratuity act, 1972.

I hereby declare that I have no family within the meaning of clause(h) of section 2 of of the said act.

(a) My father/ mother/ parents is/ are not dependent on me.

(b) My husband's father/ mother/ parents is/ are not dependent on my husband.

Whether unmarried/married/widow/widower
 DECLARATION BY WITNESSES

Fresh nomination signed/thumb impressed before me.

2.

Date :

ACKNOWLEDGEMENT BY THE EMPLOYER

 New Form No.11- Declaration Form
(To be retained by the employer for future reference)

EMPLOYEES PROVIDENT FUND ORGANIZATION

Employees provident funds scheme, 1952 (paragraph 34 & 57) &
Employees pension scheme 1995 (paragraph 24)

(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 end /of EPS1995 is applicable)

1 Name of the member

2 Father’s Name ( ) Spouse’s Name ( )
(Please Tick Whichever Is Applicable)
3 Date of Birth (DD/MM/YYYY)
4 Gender: ( Male / Female /Transgender )
5 Marital Status (Married /Unmarried /Widow/Widower/Divorcee)
6 (a) Email ID:
(b) Mobile No:
7* Whether earlier a member of Employees' Provident Fund Scheme, 1952 Yes No
8* Whether earlier a member of Employees' Pension Scheme ,1995 Yes No
Previous Employment Details - (If Yes to 7 AND /OR 8 Above)
a) Universal Account Number (UAN)
b) Previous PF a/c No
9 c) Date of exit from previous employment (DD/MM/YYY)
d) Scheme Certificate No (if Issued )
e) Pension Payment Order (PPO) No. (If Issued)
a) International Worker: Yes No
b) If Yes , State Country Of Origin (India /Name of Other Country)
10
c) Passport No
d) Validity Of Passport (DD/MM/YY) to (DD/MM/YY) To
KYC Details: (Attach Self attested copies of following KYCs)
a) Bank Account No. & IFSC code
11
b) AADHAAR Number (12 Digit)
c) Permanent Account Number (PAN), If available
UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowledge
2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present P.F
Account (The Transfer Would be possible only if the identified KYC details approved by previous employer has been
verified by present employer using his digital signature certificate)
4) In case of changes In above details the same Will be intimate to employer at the earliest
Date:
Place Signature of Member
DECLARATION BY PRESENT EMPLOYER
A) The member Mr./Ms./Mrs ......................................................has joined on …………….and has been allotted PF Number………………………
B) In case person was earlier not a member of EPF Scheme ,1952 and EPS,1995
 (Post allotment of UAN ) The UAN Allotted for the member is...........................................
 Please tick the Appropriate Option:
 The KYC details of the above member in the UAN database
 Have not been uploaded
 Have been uploaded but not approved
 Have been uploaded and approved with DSC
C) In case the person was earlier a member of EPF Scheme ,1952 and EPS, 1995:
 The above PF account number /UAN of the member as mentioned in (a) above has been tagged with his /her UAN/previous member ID as
declared by member
 Please Tick the Appropriate Option
 The KYC details of the above member in the UAN database have been approved with digital signature Certificate and transfer request
has been generated on portal.
 As the DSC of establishment are not registered With EPFO the member has been informed to file physical claim (Form13) for transfer
of funds from his previous establishment.
Date
Signature of Employer With seal of Establishment
 FORM - 2 (Revised)

NOMINATION AND DECLARATION FORM

FOR EXEMPTED / UNEXEMPTED ESTABLISHMENTS

Declaration and Nomination Form Under the Employees Provident Funds & Employees Pension Schemes

(Paragraph 33 & 61 (1) of the Employees Provident Fund Scheme, 1952 & Paragraph 18 of the Employees Pension Scheme, 1995)

1 Name (In Block Letters) :

2 Father's / Spouse`s Name :

3 Date of Birth :

4 Sex : Female

5 Marital Status :

6 Account Number :

7 Address Permanent :

Temporary :

8 Date of Joining :

PART - A (EPF)

I hereby nominate the person(s) / cancel the nomination made by me previously and nominate the person(s) mentioned
below to receive the amount standing to my credit in the Employees Provident Fund, in the event of my death.

Name of the Address Nominee's Date of Birth Total amount if the nominee is minor name &
Nominee(s) relationship with of share of address & relationship of the
the member accumulation guardian who may receive the
in provident amount
fund to be paid
to each
nominee
1 2 3 4 5 6

100
 1. *Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme, 1952 and should I
acquire a family hereafter the above nomination should be deemed as cancelled

2. *Certified that my father / mother is / are depended upon me.

*Strike out whichever is not applicable Signature or thumb impression of the Subscriber

PART - B (EPS)
Para 18

I hereby furnish below particulars of the members of my family who would be eligible to receive widow/children pension
in the event of my premature death in service.

S.No Name of the Family Members Address Age Relationship

"Certified that I have no family as defined in para 2 (vii) of the Employee’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly widow pension admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension."

Name & Address of the Nominee Date of Birth Relationship with the member

Date : Signature / Thumb impression of the subscriber

 CERTIFICATE BY EMPLOYER

Date :
Signature of the employer or other authorised officer of the establishment

Name & Address of the Factory/ Establishment